MSK: Small Conditions Flashcards
1
Q
A diagnosis of exclusion (when an illness with limp is not septic arthritis or osteomyelitis)
Presentation
A
Transient synovitis
Presentation: limp, history of viral infection, slightly unwell but apyrexial
2
Q
Total absence of limbs
A
Amelia
3
Q
Partial absence of limbs
A
Meromelia
4
Q
Some long bone absence
A
Phocomelia
5
Q
Abnormal smallness of one or more limbs (but all present)
A
Micromelia
6
Q
Presence of >5 digits on the hands or feet
A
Polydactyly
(may be inherited or teratogen induced)
7
Q
webbing between the digits
A
Cutaneous syndactyly
8
Q
fusion of bones, resulting in fewer digits
A
Osseous syndactyly
(occurs when notches between the digital rays fail to develop)
9
Q
A birth defect where the sole of the foot is turned medially and the foot is inverted
A
Talipes Equinovarus (Congenital Clubfoot)
10
Q
The most commonly affected joint in osteoarthritis
Operative management
A
Base of thumb osteoarthritis
Operative management: trapeziectomy (gold-standard), fusion, (replacement in development)
11
Q
A commonly post-traumatic osteoarthritis
Operative management
A
Ankle arthritis
Operative management: arthrodesis (gold-standard)
((mean age of presentation = 46))
((midfoot arthritis is also usually post-traumatic))
12
Q
Arthritis with negative rheumatoid factor (-ve RF)
Presentation
A
Seronegative Spondylitis/ Spondyloarthropathies
Presentation: usually asymmetrical + involving the axial skeleton, enthesitis, extra-articular features
((may be associated with HLA-B27))
13
Q
A type of seronegative arthritis affecting psoriasis patients
Presentation + management
A
Psoriatic arthritis
Presentation: arthritis, nail pitting, onycholysis, dactylitis, enthesitis
Management: DMARDs, cyclosporine, Anti-TNF, Anti-IL-17, Anti-IL-23, steroids, PT+OT
14
Q
A type of seronegative arthritis occurring after a distant infection
presentation + management (acute + chronic)
A
Reactive arthritis
Presentation: arthritis, dactylitis, enthesitis, skin + mucous membrane involvement (keratoderma, urethritis, conjunctivitis, iritis…)
Reiter’s syndrome: arthritis, uveitis, conjunctivitis
Management:
ACUTE: NSAIDs, joint injection, antibiotics (if infection still present)
CHRONIC: NSAIDs, DMARDs
15
Q
A type of seronegative arthritis associated with IBD (or occasionally with infectious enteritis, whipple’s disease, coeliac disease)
Presentation + management
A
Enteropathic arthritis
Presentation: arthritis, enthesitis
Management: NSAIDs, DMARDs, Anti-TNF, (bowel resection)
16
Q
The most common brachial palsy, caused by damage to the upper trunk of the brachial plexus (= C5,6 +/-7)
nerves involved, causes + presentation
A
Erb’s palsy
- commonly affects the suprascapular, musculocutaneous and axillary nerve
Causes: abnormal childbirth, high energy injury in adults
Presentation: waiter’s tip position*, absent biceps reflex, loss of sensation over badge patch
- Shoulder adducted + medially rotated, elbow extended + pronated, wrist flexed
17
Q
Nerve palsy caused by damage to C8/T1
Causes + presentation
A
Klumpke’s Palsy
Causes: traction on an abducted arm eg. infant being pulled from birth canal, adult catching a branch as falling from a tree
Presentation: claw hand
18
Q
Radial nerve palsy
Causes + presentation
A
Causes: entrapment (midshaft humeral fracture), compression (arm over back of chair compresses nerve in radial groove - Saturday night palsy)
SYMPTOMS(depending on site of lesion): Axilla: loss of elbow + wrist extension & sensation Arm: loss or wrist extension + sensation Forearm: loss of finger extension Wrist: loss of sensation
19
Q
Palsy caused by compression of the ulnar nerve btw the medial epicondyle and the olecranon
Presentation
A
Cubital tunnel syndrome
Presentation: numbness on ulnar side of hand, difficulty with fine tasks
20
Q
Ulnar nerve palsy
Presentation + diagnosis
A
Presentation: wasting in 1st webspace + hypothenar muscles, ulnar claw hand (hyperextension at MCPJs, flexion at IPJs)
Diagnosis: Froment’s test
- patient pinches paper btw thumb + index
- examiner pulls paper away
- In ulnar palsy: patient uses FPL instead of AP and so thumb flexes = +ve
21
Q
Common peroneal/fibular nerve palsy
Cause + presentation
A
Cause: fibula fracture
Presentation: foot drop
22
Q
Nerve palsy causing altered sensation in the lateral thigh
Cause
A
Meralgia parasthetica
Cause: compression of the lateral femoral cutaneous nerve of the thigh as it travels under the lateral border of the inguinal ligament
23
Q
A mild closed nerve injury
Pathophysiology, causes + prognosis
A
Neurapraxia
Path: a reversible block of conduction caused by local ischaemia/ demyelination
Causes: stretched, bruised
Prognosis: spontaneous, complete recovery in weeks/months
24
Q
A severe closed nerve injury
Pathophysiology, causes, investigations, prognosis
A
Axonotmesis
Path: axons are disrupted but endoneurium remains intact –> Wallerian degeneration (axon distal to injury degenerates)
Causes: stretched, crushed (direct blow)
Investigation: nerve conduction studies, tinnel’s sign (used to monitor regrowth)
Prognosis: Partial, spontaneous recovery of sensory and motor function
25
An open nerve injury
Pathophysiology, causes, investigations, prognosis and management
Neurotmesis
Path: complete nerve division, endoneural tubes disrupted --> Wallerian degeneration (axon distal to injury degenerates)
Causes: laceration, avulsion (tendon/ligament pulls off a piece of bone)
Investigation: nerve conduction studies, tinnel's sign (used to monitor regrowth)
Prognosis: poor, regrowth is unguided and may form a neuroma
Management: surgery (within 3 days) - direct repair or nerve grafting(nerve loss)
26
A genetic disorder of connective tissue causing defects in type I collagen
Presentation and management
Osteogenesis imperfecta
Presentation: FRAGILE BONES (frequent fractures), growth deficiency, ligamentous laxity (hypermobility), defective tooth formation, hearing loss, blue sclera, scoliosis, barrel chest, easy bruising
Management: IV bisphosphonates, treatment of fractures, social adaptations, genetic counselling
27
Pseudogout
Pathophysiology, triggers, presentation, diagnosis + management
Path: deposition of calcium pyrophosphate dihydrate (CPPD) in joints and periarticular tissue
Triggers: trauma, intercurrent illness
Presentation: Erratic flares, usually affects the knee
Diagnosis: X-ray (chondrocalcinosis), Microscopy of aspirated joint fluid (positively refringent rhomboid shaped pyrophosphate crystals)
Management: NSAIDs, i/a steroids
((usually affects elderly females))
28
Primary MALIGNANT tumour arising from connective tissues (e.g bones/ soft tissues)
(types + presentation of 1)
```
Sarcoma
fibrous tissue: fibrosarcoma
vascular tissue: angiosarcoma
adipose tissue: liposarcoma
in cartilage: chondrosarcoma
in marrow: Ewing sarcoma
```
OSTEOSARCOMA:
Presentation: pain, swelling, pathological fractures, loss of function
29
Suspect any swelling of being a soft tissue tumour if it is...
Diagnosis + management
+ examples
```
Painless
Hard, fixed, craggy surface
Indistinct margins
Rapidly growing
Deep to deep fascia
Subcutaneous and >5cm
Recurrent/ previous excision
```
Diagnosis: MRI
Management: Surgical excision
Examples:
- fibroma, fibrosarcoma, haemangioma, angiosarcoma, lipoma, liposarcoma
30
Partial/ total loss of use of all 4 limbs and the trunk (inc. respiratory failure)
Cause
Tetraplegia/ quadriplegia
Cause: cervical fracture --> loss of function of cervical segments of spinal cord
31
Partial or total loss of use of the lower limbs +/- trunk, bladder and bowel function
Cause
Paraplegia
Cause: thoracic/lumbar fracture
32
Syndrome caused by injury to the central cervical tracts
Cause + presentation
Central cord syndrome
Cause: hyperextension injury, common in older patients (arthritic neck)
Presentation: weakness of upper limbs
33
Syndrome caused by injured anterior spinal tracts
Cause + presentation
Anterior cord syndrome
Cause: hyperflexion injury --> anterior compression fracture --> damaged anterior spinal artery --> injured anterior spinal tracts
Presentation: profound weakness, fine touch and proprioception preserved
34
Syndrome caused by injury of a hemi-section of the spinal cord
Cause + presentation
Brown-Sequard syndrome
Cause: penetrating injuries
Presentation: paralysis, loss of proprioception + fine touch on affected side. Loss of pain and temperature on opposite side
35
Degrees of disc prolapse
Bulge – majority asymptomatic
Protrusion – annulus weakened but still intact (neck bigger that head)
Extrusion – annulus broken but disc still in continuity (head bigger than neck)
Sequestration – desiccated disc material free in canal
36
Traumatic shoulder dislocation
Types + causes, management
Types + causes:
- Anterior (90%): usually due to a fall on an outstretched, abducted arm
- Posterior (9%): usually due to epilepsy/ electrocution
- Inferior (1%)
Management: manipulation, immobilisation, PT, surgery
((high incidence of recurrence, esp. if labrum torn))
37
Pathology caused by decreased subacromial space
Management
Subacromial impingement
Management: subacromial steroid injection (US guided), PT
38
Injury to one or more of the rotator cuff muscles/tendons
Causes + management
Rotator cuff tear
Causes: traumatic, degenerative
Management: Surgery (if symptomatic), Superior capsular reconstruction (uses a cadaveric skin graft to reconstruct the shoulder capsule for massive tears)
39
A degenerative enthesopathy of elbow tendons
Presentation + management
Golfer's/tennis elbow
Presentation: Area of pain on inside(Golfer's) /outside(Tennis) of forearm
Management: Platelet rich plasma (PRP) therapy (=patient's own blood is centrifuged, PRP is injected in and around painful tendon)
40
Ganglion arising from the joint/tendon sheath on the dorsum of the foot
Presentation + management
Dorsal foot ganglion
Presentation: pressure + pain form footwear
Management: aspiration, excision
((50% rate of return))
((often an underlying arthritis/tendon pathology))
41
"Dupuytren's of the foot"
Presentation + treatment
Plantar fibromatosis
Presentation: usually asymptomatic
Treatment: avoid pressure (footwear/orthotics), excision, radiotherapy +/- excision
42
Rapid bone deconstruction occurring in 3 stages (fragmentation --> coalescence --> remodelling)
Cause, presentation, diagnosis, management
Charcot neuroarthropathy
Cause: diabetes (or any neuropathy)
Presentation: deformity, usually no pain
Diagnosis: weight bearing x-ray
Management: prevention, immobilisation + no weight-bearing until resolved, correct deformity
43
Lateral angulation of great toe
Cause, presentation, diagnosis, management
Hallux valgus ("bunions")
Cause: genetic, footwear related (female)
Presentation: pressure from shoes, pain from crossing over toes, metatarsalgia
Diagnosis: clinical, X-ray (severity)
Management: wide shoes, orthotics, activity modification, analgesia.
Osteotomy 1st metatarsal +/- proximal phalanx (recurrence inevitable)
((The pull of great toe tendons is realigned, worsening the deformity (vicious cycle)))
44
Osteoarthritis of 1st MTP joint (stiff great toe)
presentation + management
Hallux Rigidus
Presentation: asymptomatic, pain, limited ROM
Management: activity modification, footwear, analgesia, arthrodesis, cheilectomy (removal of bone spurs), arthroplasty(replacement)
45
Toes flexed at the PIP are called...
Hammer toes
46
Toes flexed at the DIP are called...
Mallet toes (often affects the longest toe)
47
Claw toes are...
Hyperextended at MTP
Flexed at PIP and DIP
((often affects all lesser toes))
48
Lesser toe deformities
(hammer, mallet, claw)
Cause, presentation, management
Cause: footwear, neuro causes, RA, idiopathic
Presentation: pain, deformity
Management: activity modification, footwear, surgery (e.g. fusion)
49
Diabetic foot ulcer
Reasons + management
Reasons: neuropathy (unaware of foot trauma), autonomic neuropathy (lack of sweating --> dry, cracked skin), poor vascular supply
Management: diabetic control, smoking cessation, activity/footwear modification. Surgery: improve vascular supply, debridement, correct deformity, amputation
50
Condition occurring when the posterior tibial tendon becomes inflamed or torn
Presentation + management
Posterior tibial tendon dysfunction
Presentation: flat feet, pain, can see all toes from behind the heel
Management: Orthotics (medial arch support), surgery (reconstruction of tendon, triple fusion)
51
A weakness of various intrinsic muscles giving a high arched foot
Causes, presentation + diagnosis
Cavovarus foot
Cause: neurological, congenital, post-traumatic
Presentation: "peekable heel sign" = heels can be seen from front, claw toes
Diagnosis: Coleman block test (Patient stands on the block with 1st-3rd metatarsal hanging freely off the edge. If hindfoot varus corrects, diagnosis = forefoot driven hindfoot varus)
52
Inflammation of the insertion of the patellar tendon into the anterior tibial tuberosity
Cause
Traction apophysitis
Cause = recurrent load
((common in adolescent boys))
53
Types of neck of femur fractures
Management
Extracapsular fracture = capsule is still intact + blood supply maintained
- always fix
Intracapsular fracture = blood supply disruption
- Undisplaced or young: fix
- Displaced or old: replace*
*hemiarthroplasty or THR
54
Causes of intoeing
```
Femoral anteversion (internal rotation)
- school age
```
Internal tibial torsion (increased thigh foot angle)
- infant
Metatarsus adductus/varus (foot deformity)
- new born
((most resolve spontaneously, NEVER operate before age 10))
55
Duration of immobilisation for types of paediatric fractures
Buckle: cast 2-4 weeks
Greenstick: cast 4-6 weeks
Complete: cast 6 weeks
((fixation is rarely required, do not overtreat))
((fractures involving growth plates can result in growth arrest, monitor if risk))
56
Fracture of bone so that a fragment of bone attached to a tendon tears away from the main mass
Management
Avulsion fracture (occurs when load exceeds failure strength)
Management: limit use, tendon retraction, OPERARTIVE: tendon reattachment, bone fixation
((Avulsion at insertion of extensor tendon into distal phalanx --> mallet finger))
57
Disc prolapse
management
- Physiotherapy
- Strong analgesia (general and neuropathic e.g. gabapentin)
About 90% settle in 3 months, if not, referral:
- Nerve root injection
- Discectomy
58
Compression of nerve roots in the lumbar spine
cause, presentation, diagnosis, management
Cauda equina syndrome
Cause: lumbar disc prolapse
Presentation: bilateral sciatica, saddle anaesthesia, bladder + bowel retention +/-overflow incontinence
Diagnosis: urgent MRI
Management: emergency lumbar discectomy
59
A neck of femur fracture where the capsule is still intact and blood supply maintained
management
Extracapsular fracture
Management: fix
60
a neck of femur fracture with a blood supply disruption
intracapsular fracture
management: fix if undisplaced or young, replace (hemiarthroplasty/THR) if displaced + old
61
Paediatric fractures
presentation, risk factors, diagnosis
presentation: buckle/greenstick (if low energy)
risk factors: previous fractures, metabolic bone disease
diagnosis: x-ray
62
chronic infection + inflammation of bones --> bone necrosis (sequestrum) --> new bone grows around the infected area (involcrum)
presentation + management
**More info in table**
Chronic osteomyelitis
Presentation: prolonged fever, weight loss, recurrent flare-ups, sinuses
Management:
- long term antibiotics (local/systemic)
- surgery (remove infection, reconstruction, amputation)
63
Tuberculosis (bone and joint)
(presentation, diagnosis + management)
**More info in table**
Presentation:
Insidious onset,
Joint pain, swelling, stiffness + deformity
Low grade pyrexia, weight loss
Diagnosis: mantoux test, x-ray, joint aspiration + biopsy, FBC, sputum + urine culture
Management: TB chemotherapy, rest + splintage
64
Acute synovitis (inflammation of synovium) with purulent joint effusion, usually affecting a single large joint
(most common organism, presentation, diagnosis, management)
**More info in table**
Acute Septic Arthritis
organism: staph aureus
Presentation: cardinal signs of inflammation on joint, reluctant to any movement, pyrexia + tachycardia
Diagnosis: markers of inflammation, blood cultures, X-ray, synovial fluid aspiration
Management: supportive, surgical drainage + lavage, IV antibiotics
65
Nerve entrapment disorder caused by compression of the median nerve at the wrist
(presentation, diagnosis, management)
**More info in table**
Carpal Tunnel Syndrome
presentation: nocturnal pain + paraesthesia in median nerve distribution (woken in night, relieved by shaking hand). thenar wasting
Diagnosis: Tinnel's test, Phalen's test (reverse prayer)
Management: supportive, corticosteroid injection, *surgical division of flexor retinaculum*
66
localised disorder of bone turnover --> bones that are bigger, less compact, more vascular + more susceptible to deformity and fracture
(trigger, presentation, diagnosis, management)
**More info in table**
Paget’s Disease of Bone
triggered: by a viral infection
Presentation: BONE PAIN, deformity/fracture, heat, may be asymptomatic
Diagnosis: ↑ serum alkaline phosphatase, X-ray, isotope bone scan
Management: (only if symptomatic/in skull)
- one off IV bisphosphonate (zoledronic acid) infusion (abolishes disease for many years)
- surgery
67
Insufficient mineralisation of the bone caused by severe nutritional vitamin D or calcium deficiency
(presentation, diagnosis)
**More info in table**
Rickets: before epiphysial growth plate fusion
Osteomalacia = after epiphysial growth plate fusion
Rickets Presentation: large head, short stature, genu varum
Osteomalacia Presentation: aching bones, muscle dysfunction
Diagnosis: X-ray (looser zones), bloods (calcium, vit D)
*Vitamin D stimulates absorption of calcium and phosphate (for bone mineralisation) from the gut
68
A large joint condition with a close relationship with giant cell arteritis, usually affecting elderly women
(presentation, diagnosis, management)
**More info in table**
Polymyalgia Rheumatica
Presentation: sudden onset of shoulder (+/- pelvic girdle) stiffness + pain, symptoms of giant cell arteritis (visual symptoms, night sweats, temporal artery tenderness, headache
Diagnosis: ESR>50, anaemia
Management: prednisolone (15mg tapered down over 1-2yrs) - dramatic response
69
Malignant bone tumours (benign skeletal tumours are much more common)
(presentation, diagnosis + management)
Presentation:
pain (persistent, increasing, nocturnal, non-mechanical, deep seated + boring), deep swelling, systemic effects of neoplasia
Diagnosis: imaging (X-ray, CT...), biopsy, fracture risk assessment (Mirel's scoring system)
Management: chemo, surgery, radiotherapy
70
You cannot determine the degree of a spinal cord injury acutely due to the possible presence of...
(presentation of syndromes)
Spinal shock (Transient depression of cord function below level of injury lasting hours-days after injury)
- Flaccid paralysis
- Areflexia
Neurogenic shock (caused by disruption to sympathetic outflow, e.g. SCIs above T6)*
- Hypotension
- Bradycardia
- Hypothermia
*onset after 24hrs, lasts for about 3 weeks
71
American spinal injury association (ASIA) grades for spinal cord injury
Grade A = complete
- No motor or sensory function distal to lesion
- No anal squeeze
- No sacral sensation
- No chance of recovery
Grade B-D = incomplete
- some function still present below injury
- more favourable prognosis
Grade E = normal motor and sensory function
72
Spinal cord injury (SCI)
cause, diagnosis + management (acute + chronic)
Cause: trauma
Diagnosis: imaging (X-ray, CT, MRI - if neuro deficit/child)
Management:
ACUTE: Prevent secondary insult! (ABCD), surgical fixation with pedicle screws for unstable fractures
CHRONIC: SCI unit, PT, OT, psychological support, urological/sexual counselling
73
Inflammation of the shoulder joint capsule (becomes tight and constricted)
(cause, presentation, diagnosis + management)
Frozen Shoulder (Adhesive Capsulitis)
Cause: 90% idiopathic
Presentation:
Phase 1: Gradual onset severe pain + stiffness
Phase 2: ↓ pain, ↑stiffness
Phase 3: ↓ stiffness (up to 2 years)
Diagnosis: clinical/ arthroscopy (x-ray = normal!)
Management: hydrodilatation, steroid injection, surgery (esp. if present late)
74
Increased proliferation of myofibroblasts in the thick fibrous fascia (palmar aponeurosis) under the skin in the hand
(cause, presentation, management)
**More info in table**
Dupuytren’s Disease
cause: genetic (autosomal dominant)
presentation: progressive loss of finger extension, lump/cord on the palm, usually painless
management: OPERATIVE! (all have a recurrence rate)
- fasciectomy
- needle faciotomy
- collagenase injections
- arthrodesis
- amputation
75
Inflamed tendon catches in the tendon sheath making it difficult to move the affected digit
(commonly affects ring finger, thumb, middle finger)
(cause, presentation, management)
Trigger Finger (stenosing tenosynovitis)
Cause: repetitive use of hand, trauma (middle aged women)
Presentation: clicking, "locking" in a flexed position (can be unlocked w/ other hand), lump in palm
Management:
steroid injection (usually curative), splintage
percutaneous release, open surgery
76
Thickening of the synovial sheath containing the tendons for extensor pollicis brevis and abductor pollicis longus
Often affects new mothers
(presentation, diagnosis, management)
De Quervain’s Syndrome
Presentation: weeks of pain localised to radial side of wrist, aggravated by movement of thumb (+/- tenderness,swelling, heat, redness)
Diagnosis: Finklestein’s test (sharp ulnar deviation with thumb in fist ilicits a sharp pain)
Management: splints, steroid injection, decompression surgery
77
Fluid filled sac arising from the joint capsule, tendon sheath or ligament, common in the wrist
presentation + management
Ganglion Cyst
presentation: firm, non-tender, changes in size, not fixed
management: reassure & observe, aspiration (60% recurrence), excision (30% recurrence)
will eventually resolve on its own
78
Achilles tendinopathy
| types, presentation, investigation, management
Paratendinopathy = histological inflammation (common in young athletes)
Tendinopathy (associated with age, obesity + immunosuppression)
Presentation: pain/tenderness following/during exercise, difficulty putting on shoes
Investigation: USS, MRI
Management: footwear modification (slight heel), immobilisation, PT
operative: gastrocnemius recession, release + debridement of tendon
79
Achilles Rupture
| presentation, diagnosis, management
Mechanism of rupture: pushing off WB foot with extended knee, unexpected violent dorsiflexion
Presentation: palpable tender gap
Diagnosis = Achilles rupture tests
- Simmond's (calf squeeze test)
- Matles ("angle of the dangle" - affected side hangs down further)
Management: splint/cast, surgery (high risk of re-rupture)
80
Chronic degenerative (not inflammatory) change of the plantar fascia
(causes, presentation, diagnosis, management)
Plantar Fasciitis
causes: running in poorly padded shoes, occupations with prolonged standing, obesity
Presentation: pain (on WB after rest, in morning)
Diagnosis: clinical (occasionally imaging)
Management: rest, ice PT, weight loss, orthotic heel pads, corticosteroid injections
3rd line: extracorporeal shock wave therapy (ESWT), platelet rich plasma (PRP), endoscopic/open surgery
81
Benign neuroma of an intermetatarsal plantar nerve – resulting in the entrapment of the affected nerve (associated with high heels)
(presentation, diagnosis, management)
Morton’s Neuroma
Presentation: pain on WB, altered sensation in affected webspace (usually 2nd/3rd) - sometimes described like a pebble in the shoe, mulder's click
Diagnosis: USS, MRI
Management: corticosteroid injection, surgical excision
82
Meniscal Tear
| presentation, diagnosis, management
Presentation: pain + tenderness, clicking, locking (can't get up from deep flexion), intermittent swelling
Diagnosis: MRI
Management: Rest, NSAIDs, PT (hamstring + quadriceps strengthening)
Arthroscopic repair/resection*
*preserve meniscus to reduce arthritis risk
((meniscal blood supply poor so healing poor))
83
Necrotic lesion affecting articular cartilage and subchondral bone (most commonly affecting the knee
(causes, presentation, diagnosis, management)
Osteochondritis Dissecans (OCD)
causes: hereditary, traumatic, vascular
Presentation: poorly localised pain on activity, recurrent effusions, locking + stiffness
Diagnosis: tunnel view x-ray, MRI
Management: restricted weight bearing, ROM brace, Arthroscopic/open fixation, Arthroscopic subchondral drilling
84
Anterior Cruciate Ligament (ACL) Tear
| cause, presentation, diagnosis, management, associated with...
Cause: non-contact pivot injury
Presentation: "pop" sound, immediate swelling (haemoarthrosis), deep pain, +ve anterior draw test, able to walk in straight line
Diagnosis: x-ray, MRI
Management: PT (quadricep programme), ACL reconstruction
((Frequently associated with a segond fracture = # of lateral tibial condyle))
85
Medial Collateral Ligament (MCL) tear
(most common ligament injury of the knee)
(cause, presentation, diagnosis, management, associated with...)
Cause: severe valgus stress (usually contact related)
Presentation: "pop" sound, severe pain (esp. in full extension), swelling, opening on valgus stress
Diagnosis: X-ray (may be normal), MRI
Management:
usually managed non-operatively (rest, NSAIDs, PT, brace)
operative repair/ reconstruction
((associated with ACL tear + medial meniscus tear))
86
Labral tear
| presentation, diagnosis, management
Presentation: groin/hip pain, snapping sensation, locking, +ve FABER* if anterior
Diagnosis: X-ray, MRI
Management: activity modification, NSAIDs, PT, steroid injection
Arthroscopic resection/ repair
*=pain on FABER
87
complete joint disruption (lack of congruity of articular surfaces)
(diagnosis + management)
Dislocation
diagnosis: X-ray, assess for associated injuries + neurovascular damage
Management: reduction (using sedation + muscle relaxant), surgery
88
partial dislocation (not fully out of joint)
Subluxation
89
Presentation of these dislocations:
```
Ant. Shoulder
Post. Shoulder
Post. Elbow
Post. Hip
Ant./post. Knee
Lateral ankle
Lateral subtalar joint
```
Ant. Shoulder = squared off
Post. Shoulder = locked in internal rotation
Post. Elbow = prominent olecranon
Post. Hip = flexed, internally rotated, adducted, short leg
Ant./post. Knee = loss of normal contour, extended
Lateral ankle = externally rotated, prominent medial malleolus
Lateral subtalar joint = laterally displaced calcaneus
90
Displacement of the femoral head due to disruption of the growth plate
(typically affects, presentation, diagnosis, management, outcome)
Slipped Capital (upper) Femoral Epiphysis (SCFE/SUFE)
Affects: 9-14yr old, overweight, boys
Presentation: hip/knee pain, limp, reduced internal rotation
Diagnosis: lateral x-ray "ice-cream falling off cone"
Management: percutaneous screw fixation to prevent further slipping (if stable), reduction
Outcome: AVN (likely if unstable), deformity, osteoarthritis, limb length discrepancy, impingement
((stable = able to WB, unstable = unable to WB))
91
Disrupted blood supply to head of femur --> AVN --> Revascularisation (pain) --> Reossification --> deformity
In children
Affects..., presentation, diagnosis, management
Perthes Disease
Affects: primary school age, boys, short stature
Presentation: knee pain of exercise, stiff hip, limp
Diagnosis = X-ray
Management: maintain hip motion, analgesia, activity modification, if >7yrs consider osteotomy
92
Abnormalities of bone formation at the femoral head or acetabulum resulting in impingement of the femoral neck against the anterior acetabulum. Common in young active patients
(types, presentation, diagnosis, management)
Femoroacetabular Impingement (FAI)
Cam lesion: abnormality of femoral head
Pincer: abnormality of acetabulum
Presentation: reduced flexion + internal rotation, +ve FADIR*
Diagnosis: X-ray, MRI
Management: NSAIDs, PT,
arthroscopy (shave down defects)
Open surgery: resection, periacetabular osteotomy, arthroplasty (non-operative prefered for athletes)
*+ve FADIR = pain on flexion, adduction + internal rotation
93
Inflammation of the trochanteric bursa (= sandwiched btw hip abductors and iliotibial band)
(cause, presentation, diagnosis, management)
Trochanteric Bursitis
Cause: trauma, overuse (runners), abnormal movements due to other pathology
Presentation: very localised lateral hip pain, worst in abduction
Diagnosis: MRI, USS, X-ray(for cause)
Management: NSAIDs, activity modification, PT, corticosteroid injection, bursectomy(rarely)
94
Condition of childhood where the hip socket doesn’t fully cover the ball
(risk factors, presentation, diagnosis, management)
Developmental Dysplasia of the Hip (DDH)
Risk factors: girls, first born, high birth weight, breech presentation, apaches+navajos, eastern european
Presentation: limp
Diagnosis: selective US screening if high risk factors, Barlow's test
```
Management:
<3 months: harness (90%cured for life)
>3 months: plaster for 3 months
After walking: surgery
>6yrs+bilateral/ >10 + unilateral: leave
```
95
A fracture involving direct communication between the external environment and the fracture
Diagnosis + management
An open fracture
Diagnosis: X-ray, photograph, repeated neurovascular exam
Management: ATLS assessment + treatment, tetanus + antibiotic prophylaxis, stabilise limb
Emergency surgery (within 6hrs if normal operating hrs)
- debridement + fixation
- skin coverage
- amputation (dual consultant decision) - if insensate/irretrievable damage
((most common = fingers and tibial shaft))
96
Gustilo grading of open fractures
| Type I, II, III
TYPE I
- Wound <1cm
- Low energy, simple fracture pattern
TYPE II
- Wound <10cm
- Moderate soft tissue damage, no tissue flap or avulsion*
- Simple fracture pattern
TYPE III
- Wound >10cm
- High energy, severe fracture +soft tissue damage
- Any gunshot, farm/marine accident, segmental fracture, bone loss…
97
Multi-system autoimmune disease treatment
| + what it treats
Mild organ threat: Hydroxychloroquine
Moderate organ threat: Azathioprine, Methotrexate, Mycophenolate
Severe organ threat: Cyclophosphamide, Rituximab
Treats: SLE, scleroderma, sjogren's syndrome, autoimmune myositis, mixed connective tissue disease, ANCA associated vasculitis
98
An autoimmune connective tissue disorder involving:-
- tissue distal to elbows and knees if limited
- including trunk tissue if diffuse
(presentation, complications, diagnosis, management)
Scleroderma
Presentation: morphea (painless discoloured skin patches), calcinosis (calcium deposits in fort tissue), Reynaud's, sclerodactyly (thickening and tightening of finger and toe skin), telangiectasia, oesophageal dysmotility
Complications if diffuse: pulmonary fibrosis, renal crisis, small bowel bacterial overgrowth
Diagnosis: serum autoantibodies (ANA), biopsy
Management: Multi-system autoimmune disease treatment
99
An autoimmune connective tissue disease that causes inflammation of exocrine glands, usually affects women
presentation, complications, diagnosis, management
Sjogren's Syndrome
Presentation: may be asymptomatic, dry eyes and mouth for >3 months, parotid enlargement, systemic symptoms (fatigue, fever, myalgia, arthralgia), rarely affects major internal organs
Complications: lymphoma, neuropathy, purpura, interstitial lung disease, renal tubular necrosis
Diagnosis: Schirmer test (filter paper under eyes gives objective evidence of dryness), serum autoantibodies (ANA), biopsy, annual screening for complications
Management: Multi-system autoimmune disease treatment
100
Autoimmune connective tissue diseases such as polymyositis, dermatomyositis
presentation, complications, diagnosis, management
Auto-immune myositis
Presentation: symmetrical diffuse proximal muscle weakness
dermatomyositis: photosensitive skin involvement (heliotrope rash*, gottron's papules**, shawl sign)
Complications: cancer, interstitial lung disease
Diagnosis: biopsy, serum autoantibodies (ANA)
Management: Multi-system autoimmune disease treatment
* =periorbital pink-purple rash
* * = red lesions over bony prominences
101
An overlap syndrome containing presentations from many autoimmune connective tissue diseases disorders
presentation, diagnosis, management
Mixed connective tissue disease
Presentation: soft-tissue swelling, raynaud's, myositis, arthralgia
Diagnosis: biopsy, serum autoantibodies (ANA)
Management: Multi-system autoimmune disease treatment
102
Inflammation of large arteries
classification criteria, management
Giant cell arteritis
Classification criteria = any 3 of the following…
- Age at onset ≥ 50 years
- New headache
- Temporal artery tenderness/reduced pulsation
- ESR ≥ 50
- Abnormal temporal biopsy
Management: high dose prednisolone
103
A group of systemic autoimmune diseases characterised by inflammation and destruction of small vessels
conditions, diagnosis, management
ANCA Associated Vasculitis
Conditions:
Granulomatosis with polyangiitis (Wegner’s)
- Resp tract/ necrotizing glomerulonephritis
Microscopic polyangiitis
- Necrotising glomerulonephritis/ pulmonary capillaritis
Eosinophilic granulomatosis with polyangiitis
- Resp tract (Associated w/ asthma + eosinophilia)
Diagnosis: serum autoantibodies (ANCA), biopsy, angiogram
Management: Multi-system autoimmune disease treatment
104
Which artery when damaged leads to AVN
medial femoral circumflex artery
